This study shows how a model of intersectoral intervention, to which a group of children under one year of age was exposed for ten months, was able to change the nutritional status, as measured by anthropometry, i.e., H/A indicator, in 43.14% of the participants undergoing the intervention. Four children out of ten moved positively in their growth trajectory; these results were based on final post-intervention measurements.
After the intervention, the group of children who showed a positive change in height <-2 standard deviations (4.52%), that is, classified as stunting, moved even more positively in their growth trajectory and showed total recovery of their nutritional condition, becoming appropriate for their age. These findings, when contrasted with the scientific evidence on health and nutrition interventions focused on reducing the delay in height in children under five years, are relevant because it has been described that those interventions of greater efficacy to reduce the prevalence of delay in height in children under five years are those that at least obtained a 3.0% change in the prevalence of height delay in the intervened population, with an exposure greater than or equal to 12 months (9) .
Faced with the relationship between anthropometric indicators of H/A and W/H, after implementing the intervention model, the prevalence of risk and/or excess weight-for-height decreased from 17.90–2.10%; that is, only two out of ten children involved in the intervention maintained their double burden of malnutrition, a finding that shows that the actions proposed in the intervention were effective in this group because the prevalence of this double condition was reduced by slightly more than 15 percentage points and scientific evidence has catalogued as effective interventions those that achieve at least 3.0% (baseline: 17.90%; post-intervention: 2.10%) (9) .
The result of double burden makes us reflect, as other studies have previously stated, on the importance of monitoring and intervening in height gain in early childhood as well as in issues related to adequate weight gain for height; from the perspective of public health, comprehensive policies should be established to mitigate malnutrition problems, both due to excess weight and delayed height (10, 11) .
The increase in malnutrition due to excess in childhood concomitant with the delay in height is a predictor of the future presence of chronic diseases such as obesity, diabetes, dyslipidaemia and hypertension, among others (12). Important outcomes are predictors of the quality of life of the adults who will be the fathers and mothers of the children to be born and on whom an own health and nutrition map will be established, partly inherited by the deficiencies of their parents. There is evidence that has shown how the nutritional recovery of an individual that occurs during the first two years favourably affects variables such as birth weight, schooling, human capital, and the presence or absence of future diseases (13) .
In respect to the magnitude of the change, it was found that children six months or younger who were at risk of stunting or with stunting, had a greater than 70.0% probability of approaching or entering their proper growth trajectory after intervention compared to children older than six months, who had less than a 70.0% probability. This result confirms, as several studies have described, the importance of implementing specific interventions on length delay during the most effective window of opportunity, that is, from gestation through the first two years of life (14, 12, 1).
It was found that the probability of approaching or entering an adequate growth trajectory after intervention increased when the child was in a household where the head of household was a woman. A possible explanation for this result is argued by a study that states that empowered mothers (via head of household, for example) have fewer time restrictions to dedicate to their children, in addition to having better mental health and more control over children and household resources, greater self-esteem and better information regarding and access to health services. This implies that empowered mothers take better care of themselves and their children, which is expected to have benefits on the nutritional status of the latter (15).
Similarly, it has been shown that interventions that include timely education for caregivers for the age and current condition of the children, systematic monitoring, effective connection with health care and other sectors related to early childhood care, including basic sanitation and drinking water, developed in low- and middle-income countries are more effective for better outcomes related to child nutrition (9).
For example, at the end of the intervention, 80.9% beneficiary families had their comprehensive assessment of growth and development cards for their children and were able to explain their importance; their use demonstrates caregiver empowerment through exercising their rights and duties as citizens, benefiting them as a community. Necessary conditions for caregivers to effectively access health care relevant to the age of their children are key factors for the prevention and/or management of delayed height in the window of opportunity of early childhood (1).
The educational strategy used for the intervention axis related to caregiver education was constructed using counselling as a methodology, whose principle is to work from the needs expressed by those who will be subjects of education using the skills allowing improving the process of communication between the facilitators and the participants so that they acquire the necessary skills for informed decision-making (16).
In this study, at the end of the intervention, seven out of ten children continued breastfeeding (73.7%) as part of their eating pattern; in comparison with the breastfeeding practice at baseline, improvement in practice was evident. Evidence has shown that using counselling contributes positively to practices related to the duration of exclusive and continued breastfeeding (17) with adequate complementary feeding until two years and older.
Similarly, an improvement in the general practice of breastfeeding has been related as a function of maternal educational level and to mothers being immersed in protective environments and surrounded by community supporters (18). These elements were also observed; most of the mothers had completed their high school education and a significant proportion, by the end of the intervention, had completed higher technical studies, a finding that suggests the importance of consolidating intersectoral strategies to favour the formal education of mothers and caregivers.
The probability of approaching or being in the appropriate growth trajectory, after the intervention, was reduced by 45.9% if the children were fed with formula milk compared to those who did not receive it. This result is consistent with other studies. A study conducted in public hospitals in Hong Kong found for a sample of 642 preterm children with low weight, those fed during their hospitalization with breast milk had a better z-score for height-for-age upon discharge than children fed formula milk because children fed formula have a higher risk of gastrointestinal infections that affect weight and height (19) .
These results reaffirm breast milk providing nutrients children need for healthy growth and development during their first two years and beyond; therefore, it is necessary that social programs have as a priority the promotion and protection of this practice, as established by the WHO: exclusive breastfeeding during the first six months of life and adequate complementary feeding until two years or more (20).
According to the age of the children, 29.2% consumed eggs at baseline (older than six months), and 83.32% consumed eggs at the post-intervention measurement. That is, eight out of ten children were eating eggs as one of their main sources of protein. After the intervention, nine out of ten children (90.21%) had food sources of animal protein as part of their eating pattern. This result could be related to food voucher delivery, part of the social focus of the intervention model.
These vouchers were redeemed monthly by each beneficiary family in the study in a local supermarket. The redemption had a list of foods that included healthy food. This list was defined taking into account the recommendations for feeding for early childhood defined by the governing body of the sector for Colombia, ICBF (21). Additionally, the proposed form of redemption favoured families having autonomy in decision-making for the purchase and preparation of food. This was mediated by the collaboration between the axes of education for caregivers and social care.
According to the evidence, the way to effectively intervene in height delays in early childhood requires comprehensive intersectoral work that encompasses cross-cutting actions that can account for most of the determinants of this condition, as the intervention of this study developed (12, 1) .
In relation to the sociodemographic results:
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Family income plays a fundamental role in the recovery of stunting. A World Bank study (22) argues that the link between income and nutritional status occurs mainly because households with higher income levels can invest more in consumption and variety of foods, in addition to having better quality of services and more resources to invest in the care of their children. This relationship has been validated by different studies using different measures to determine income as monthly wages (23, 22) or assets in the home (24), among others.
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The obtained results of mother’s education level were not consistent with scientific evidence. Different authors have referred to how the children of more educated mothers present better results for the nutritional indicator height-for-age (13, 12, 2). Education empowers women to make decisions they could not make in the absence of it, such as having fewer children or using health services in a better way, which leads to greater development in their children, both physical and emotional (25). In the present study, this relationship was not evidenced.
The intervention model implemented in the study is in line with several of the recommendations suggested by authors such as Butta, who refers to following effective actions in public health that make it possible to reduce height delays when implemented during early childhood: (i) folic acid supplementation in the preconception period; (ii) dietary supplementation to obtain a positive energy and protein balance in pregnant women; (iii) calcium supplementation for mothers; (iv) multiple micronutrient supplementation during pregnancy; (v) promotion of breastfeeding; (vi) adequate complementary feeding; (vii) administration of vitamin A; (viii) preventive zinc supplementation in children from six to 59 months; (ix) treatment of moderate acute malnutrition; and (x) treatment of severe acute malnutrition (26).
Limitations
The sampling for this study was consecutive, and families were recruited mainly by mass communication strategies and the “snowball” technique. This sample determination did not allow us to extrapolate the results to the entire population in Bogotá. The intervention model developed and the results of the study directly pertain to the specific composition of the sample, mainly in terms of socioeconomic indicators; therefore, the magnitude of the change obtained on the height/age indicator of the beneficiaries of the study is specific to this group of children under the conditions that were treated